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WHY ARE WE PRONE TO KNEE PROBLEMS?
Yoga Therapy for Your Knees
With a simple anatomy lesson, isometric exercises, and attention to alignment in standing poses, you can undo chronic pain in your knees.
If you have chronic pain in your knees, if they “snap, crackle, and pop” when you bend or extend them, or if they tend to hyperextend, you may have improper tracking or “dislocation” of the kneecap. This misalignment causes the most common kind of chronic knee pain and damage to the knee joint, which develop slowly over time.
Here’s a simple anatomy lesson: The kneecap is designed to slide along a groove in the femur, and it has to move smoothly within that groove to do its job well. If it goes “off track” (and it often does) it grinds away at the cartilage underneath and destabilizes the knee. The ensuing wear and tear is a key reason for knee replacement surgery, which a lot of people believe is necessary because they think the cartilage is “gone.” But the truth is that cartilage can grow back, albeit slowly. The main problem is that if we don’t correct the imbalanced pull of muscles on the kneecap, we will continue to grind our cartilage down faster than our body can replenish it. So why does the kneecap go off track? The cause lies mainly in the quadriceps, a group of four muscles that merge just
above the knee into a single quadriceps tendon. This tendon surrounds and attaches to the kneecap, continuing down below the kneecap as the patellar ligament, where it attaches to the tibia (shin bone). The kneecap serves an important mechanical function. The quadriceps tendon passes over the kneecap like a rope over a pulley, and the kneecap—like a pulley—increases the strength of the quadriceps to straighten the leg 30 percent. Together, the quadriceps and the kneecap form the “extensor mechanism” for straightening the leg. Misalignments come when the “rope” of the quadriceps exerts a sideways pull on the kneecap “pulley,” creating friction in the mechanism. Hatha yoga has a lot to offer to correct this misalignment; the standing poses are especially effective. But be forewarned: Misalignments of the knee in various asanas can amplify the imbalances that lead to injury and can aggravate existing problems instead of correcting them. The good news is that good alignment and proper tracking are easy to achieve— once you know what to pay attention to.
Our bodies are predisposed to injuries of the extensor mechanism because the hip joints are wider than the knees in a neutral standing position. The natural “Y”-shaped configuration to the leg bones promotes uneven contraction of the quadriceps, and problems such as hyperextension of the knees make these natural imbalances even worse. As a result, when we contract the quadriceps to straighten the leg, the unevenness of the contraction tends to pull the kneecap to the outside, thanks to the greater pull of the outermost quadriceps (the vastus lateralis). The innermost quadriceps (the vastus medialis) is most responsible for counteracting this pull. This muscle tends to be weak and underused, while the outer thigh muscle tends to be stronger from overuse. So if you want to keep the knee healthy (i.e., tracking properly in its
femoral groove), you need to learn to strengthen the vastus medialis. In fact, physical therapists consider exercises to strengthen this neglected muscle key in the rehabilitation of knee injuries.
THE CHALLENGE OF WORKING WITH THE INNER QUAD
Yoga students are often told to “lift the kneecaps” in straight-legged poses to engage their quadriceps and, ostensibly, protect their knees from hyperextension. But lifting the kneecaps in a healthy and balanced way requires focused attention, especially if you already have problems in your knees. This is easy enough to check. Sit or stand with your legs straight and your feet parallel to each other, then engage your thigh muscles so that your kneecaps “lift” or pull toward your hips. Do your kneecaps move up in a straight line, or do they move in an angle toward the outside of your knees? If the latter is the case,
IN A RELAXED
standing posture the hip joints and knees form a Y-shaped angle, which encourages an uneven pull to the upper outside of the kneecap.
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WHEN THE KNEECAP slides straight up and down the femoral groove the joint remains healthy. If it slides up and to the outside it will grind away the cartilage and damage the joint.
yoga + joyful living july - august 2007 yogaplus.org
yogaplus.org january - february 2007 yoga + joyful living
because you can feel the vastus medialis firming most only in the last 10 to 20 degrees of knee extension. although engaging the vastus medialis properly can prevent hyperextension of the knee. Roll up a small blanket or sticky mat and place it under your knees to preDoug Keller’s yoga journey includes 14 years of practicing in Siddha Yoga ashrams. and nearly a decade of teaching in the United States and abroad. then you need to strengthen the vastus medialis. pulls the kneecap up and inward. Repeat this exercise with the other leg. yoga + joyful living july . making it even harder to work with. Find your vastus medialis. essays. Consequently. Extend your leg fully and see if you can engage the inner part of the quadriceps—where you’re touching with your fingers—as strongly as you can engage the outer part of the quadriceps. rotate your legs out 10 to 15 degrees (if the soles of your feet were on a clock face. with your legs extended forward. place your fingers about one inch above the inner (or medial) corner of your kneecap. and then walk your fingers about one and a half inches toward the inner thigh. structural misalignments that cannot be changed (like being knockkneed or bowlegged) tend to limit the vastus medialis’s proper functioning— and can even weaken it in relation to the other quadriceps muscles.august 2007 yogaplus. This is critical. rather than pulling to the outside. making sure you don’t extend the leg so hard that you feel locking or pinching in the knee. sit in dandasana (staff pose). Continue to strengthen the vastus medialis in bent-knee warrior poses. intensive training in the Iyengar and Anusara methods. rather than relying on the strengthening exercises to prevent it. So it takes focused attention to even feel and understand what the muscle does. Strengthen it with small extension exercises. Repeat on the AS THE RIGHT LEG straightens. When the muscle is overdeveloped it pulls the kneecap out of the femoral groove. Repeat this for two more rounds. 1/6 Vertical 2 1/8 x 4 1/2 1/6 Vertical 2 1/8 x 4 1/2 1/6 Vertical 2 1/8 x 4 1/2 82 Photo credit. because the habit of hyperextension will otherwise pull you right back into your imbalanced patterns of knee extension even after you do the work of strengthening the vastus medialis. the inner quad.august 2007 yoga + joyful living 83 . 2. VASTUS LATERALIS. Straighten your leg slowly to feel the quadriceps engage. Next. This is the vastus medialis. Next. Keep your leg aligned so that your kneecap faces straight up toward the ceiling. STRENGTHENING YOUR INNER QUAD vent hyperextension while your quadriceps are contracted. the inner quadricep. First. 3.org yogaplus. Finally. This has its challenges. physical therapists consider exercises that strengthen this neglected muscle key in the rehabilitation of knee injuries. You will feel it fully engage as your leg straightens completely. and learn how to use it properly. the inner quadriceps. Incorporate that work into straightlegged asanas. In fact. Second. 4. it’s important to consciously avoid hyperextension in the first place. the inner quadriceps muscle.com.org july . doing so is essentially useless if the knee is already hyperextended. you’ll feel the vastus medialis engage. it can be difficult to find and isolate this muscle. It counters the pull of the vastus lateralis.If you want to keep the knee healthy you need to strengthen the vastus medialis (the inner quadricep). pulls the kneecap up and outward. To do this. then release. Watch how your kneecap moves in a straight line along the center of the knee joint when your quads are engaged in a balanced way. You’re looking in particular for the firming of the teardrop-shaped muscle just under your fingers. the outer quadricep. 1/3 Page Ad Square 4 9/16 x 4 3/8 Isometric extensions will help you identify the inner quad and its action as you strengthen it. do the same exercise without rotating the leg out. Asana instruction. VASTUS MEDIALIS. and other enlightening information is available on his website: DoYoga. your toes would be pointing to one o’clock). Hold the contraction for 8 to 10 seconds. Support your upper back against a wall if that’s more comfortable. Here’s what you can do to keep your kneecaps tracking properly: 1. To find the vastus medialis. Use your fingers to make sure it’s as engaged as much as the outer quadriceps.
WARRIOR II Ground the inner heel and toe mound while lifting the arch up all the way through the inner knee as your outer hip drops down. you’ll feel a stronger stretch along the inner edge of your thigh. In this case the muscles along the outer thigh tighten. it’s a sign that your knee is going too far beyond your heel. are in the same plane by allowing a slight turn of the hips. disable the vastus medialis and increase the muscular imbalances that cause wear in the knee. for this is a sign that your knee is turning inward too much. Keep your torso upright as you bend your right knee. As a result. are particularly effective for strengthening the vastus medialis. in which working the vastus medialis consciously is more challenging. Second. in which the front leg is bent and the back leg is straight. widen the distance between your feet. If your toes are gripping. Then The standing poses of hatha yoga provide powerful and effective means for strengthening and stabilizing our knees. and right hip joint are all aligned. make sure your knee is bent properly to a right angle. as you bend your knee. The challenge of aligning the knee is to keep your inner heel and big toe mound grounded while keeping the inner arch of the foot lifted. so that the knee turns more toward the little toe. step your feet wide apart. stressing the inner knee. you’ll see your kneecap draw straight up your leg. If you feel pressure in the knee joint. This happens especially when the arch of the foot collapses. the knee falls inward. Turn your left foot in about 30 degrees and your right leg out 90 degrees. the knee can easily hyperextend and lock into that position.) To achieve this. maintaining the straightness of your leg without locking the knee. and hip as in warrior pose. the vastus medialis gets a much-needed workout that brings it into balance with the other quadriceps. so the leg is bent at a right angle. which places stress on the inner knee and prevents you from strengthening the quadriceps in a balanced way. Bend your right knee slightly and align your heel. it is also engaged and strengthened when the knee is bent at a 90 degree angle and the leg is bearing weight––as long as the knee is positioned vertically over the heel. This is the case in a well-aligned warrior pose. Be careful not to overstretch: use the support of a block for your hand if you need it. when you bend your knee. kneecap. When the weight shifts to the outer heel the knee splays out over the little toes and stresses the outer knee. so the weight is centered in your heel. Even when your stance is the proper width and your knee bends to a right angle. Your feet should be roughly beneath your wrists. yoga + joyful living july . you’ve probably relaxed the vastus medialis and hyperextended your knee. knee. knee and right hip would all be touching it. You can protect your knees and strengthen the vastus medialis by following three basic rules for the warrior poses.august 2007 yoga + joyful living 85 . and the inner heel remains grounded. TRIKONASANA straighten the leg mindfully. from your inner knee back toward your sit bone. If you engage this muscle properly and your leg is aligned as you straighten it. (If you were doing the pose next to a wall. This will make your leg spiral out as you bend it. until your heel. First. Keep the vastus medialis firm and lift along your inner thigh. turning your left foot in 45 degrees and your right leg out 90 degrees. if done with proper alignment and action. and the outer (lateral) side of the knee is stressed. Now you can apply these same actions to the straight-legged poses like trikonasana. These two actions—grounding and lifting—will keep the knee from turning inward or outward too much. a common—and harmful—misalignment is to let the thigh turn inward so that the knee points more toward the big toe. let your outer hip descend toward the floor (as if you had something heavy in your hip pocket) as you lift energy from your inner arch up through your inner knee. If the knee goes beyond your ankle and your weight shifts into your toes. the warrior poses (virabhadrasana I and II). while extending your arms out to either side. But if you let go of the vastus medialis even for an instant. Step your feet wide apart. on the other hand. make sure it’s above the second toe and that both the toe and the knee are on the same plane as the sit bone. make sure that the heel. In this case too. causing the inner heel to lift. Come out of the pose and try again. Third. To come into the pose. CONCLUSION 1/3 Page Ad Vertical 2 1/8 x 8 7/8 TO PROTECT THE KNEE IF THE VASTUS MEDIALIS is not properly engaged 84 Photo credit. Misalignments. A less common misalignment is to shift the weight to the outer edge of the foot. the vastus medialis doesn’t function properly. your outer right ankle. kneecap. The purpose of these three actions in the bent leg is to ensure that all four quadriceps muscles are working harmoniously to stabilize the knee. draw the energy from the inner arch up through the calf to your inner knee. You can do these exercises several times a day—just be careful not to fatigue the muscle by doing too many sets at a time. toward the edge of your mat. engaging the vastus medialis. gently pinch your thigh above the inner knee to check that the muscle there—the vastus medialis—is as firm as the thigh muscles at the outer knee.+ TRIANGLE POSE If the vastus medialis is engaged properly you’ll feel a stretch along the inner thigh and the kneecap will slide along the femoral groove. and you’ll find it nearly impossible to lock your knee. We sometimes compensate for this collapse by shifting weight to the outer edge of the foot.august 2007 yogaplus. and hip joint of your bent leg Proper alignment of the knee in the warrior poses automatically gives the vastus medialis a healthy workout. Fold at the hip crease to take trikonasana to the right. Make sure your knee does not go beyond your ankle and toes: Keep the shin vertical while striving to bring the thigh parallel to the floor. As a bonus for good alignment. Lift your toes to help engage and lift the inner arch. But this stresses the outer knee and defeats the purpose of the pose.org july . The vastus lateralis then pulls the kneecap outward. Proper alignment in the warrior pose allows the vastus medialis to work in harmony with the other quadriceps to align and strengthen the extensor mechanism of the knee. Turn your head to look out over your right fingertips. Because although it’s easiest to isolate this muscle’s action when the leg is fully extended.org yogaplus. especially in the last 20 degrees of extension. so that your knee remains directly over your heel and does not turn inward. helping us to overcome structural imbalances that might otherwise lead to chronic wear and tear (and ensuing pain) in your knees. To confirm this. A little extra mindfulness in aligning and working our legs in these poses will enhance the natural therapeutic benefits these poses have to offer. THE WARRIOR POSES Among the traditional asanas.other leg. which prevents hyperextension. don’t let the inner arch of your foot collapse.
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